Core Worker Exemption Application Form
About this form
This form is for individuals who have been convicted of a specified offence and
who want to apply for an exemption under the Vulnerable Children Act 2014 in
order to be employed or engaged as a core worker. Please read this form along
with the Core Worker Exemption Application Guidance for Individuals document.
Please complete all sections in full using BLOCK CAPITALS.
Incomplete forms may be returned for completion.
Applicant
Details
1
Mr
Mrs
Ms
Miss
Other
First and middle names
Surname or family name
Date of birth
Day Month
Place of birth
Year
Country of birth
Gender
Occupation and employer if currently employed
Educational institute if currently enrolled
Home phone
Mobile phone
Email
NZ Driver Licence Number
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Core Worker Exemption — IN CONFIDENCE
Are you or have you ever been known by any other name? (eg married or maiden name,
nickname, alias or alternative name(s), name changed by deed pool or statutory declaration)
Yes
No
If ‘Yes’ provide details in box below:
Current address:
Flat/House number
Street name
Suburb
Town/City
Country
Post Code
Provide last three New Zealand addresses (excluding current address)
Flat/House number
Street name
Suburb
Town/City
Country
Flat/House number
Post Code
Street name
Suburb
Town/City
Country
Flat/House number
Post Code
Street name
Suburb
Town/City
Country
Post Code
If you are unable to provide three previous New Zealand addresses please state why below.
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Core Worker Exemption — IN CONFIDENCE
!
If you have lived outside New Zealand for more than 12 months in your life, please list here the
If you have lived in
Australia for 12 months
or longer after the age of
18, please complete the
paperwork for an
Australian Police Check.
This form is available at:
countries where you have lived, and period you lived there, eg Australia, May 2010–July 2013.
http://www.afp.gov.au/
what-we-do/policechecks/nationalpolice-checks
What is your preferred method of communication?
We understand that the nature of the material you are providing to us is
personal and sensitive. We wish to keep your application as private as
possible. To assist us with this, please let us know the best way to
communicate with you about your application.
Include your completed
form with your application.
Please contact me via:
Mobile phone
Home phone
Email
Statutory
Declaration
Regarding
Convictions
!
I
2
(first name, last
name) of
(place of abode and occupation)
Please note that this
section of your form
must be witnessed and
signed by a Justice of the
Peace, or other person
authorised to take a
statutory declaration.
If you cannot recall
details we recommend
you contact the Courts
to obtain a copy of your
sentencing notes.
solemnly and sincerely declare that:
I am aware that I am subject to the Vulnerable Children Act workforce
restriction because I have been convicted of a specified offence(s). I am
applying for a Core Worker Exemption in regard to this specified offence(s)
Description of specified offence 1: (eg sexual violation under section 128B of the Crimes Act 1961)
Date of conviction
Sentenced imposed (if any)
Sentence expiry date (if any)
!
Description of specified offence 2 (if applicable): (eg sexual violation under section 128B
of the Crimes Act 1961)
If you have more than
two specified offences,
please print and attach
an additional copy of
Section 2 of this form.
This additional section
must also be witnessed
and signed by the Justice
of the Peace, or other
person authorised to take
a statutory declaration.
Date of conviction
Sentenced imposed (if any)
Sentence expiry date (if any)
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Core Worker Exemption — IN CONFIDENCE
I am currently subject to conditions imposed under the Parole Act 2002,
the Criminal Justice Act 1985 and the Sentencing Act 2002.
No
Yes (please write conditions below)
Parole Act/Criminal Justice Act conditions (if applicable)
No
Yes (please write conditions below)
My name and contact details, as recorded in Section 1 of this form, are accurate.
I make this solemn declaration conscientiously believing the same to be true
and by virtue of the Oaths and Declarations Act 1957.
My signature (sign full name here)
Declared at (place name, date)
Signature and name of JP Justice of the Peace (or other person authorised to take
statutory declaration)
Proof of
identity
3
Consent to
Disclosure –
New Zealand
Police
4
Please attach a clear photocopy or scan of your identification. It must show
your signature. This can be any one of the following:
• New Zealand Driver Licence – can be current or expired within the last two
years, but cannot be cancelled, defaced or a temporary licence.
• New Zealand Passport – can be current or expired within the last two
years, but cannot be cancelled or defaced.
• Overseas Passports – must be current and cannot be expired,
cancelled or defaced.
• New Zealand Firearms Licence – must be current and cannot be
expired or defaced.
If you cannot supply any of the above forms of identification, you need to
confirm your identity in Section 8.
I authorise the New Zealand Police to provide the Ministry of Social
Development with information relating to my specified offence(s) as detailed
in Section 2.
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Core Worker Exemption — IN CONFIDENCE
VCA CORE WORKER EXEMPTIONS
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Core Worker Exemption — IN CONFIDENCE
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Core Worker Exemption — IN CONFIDENCE
Consent to
Disclosure –
Department of
Corrections
5
Privacy
Statement
6
I authorise the Department of Corrections to provide the
Ministry of Social Development with information, conditions and reports relevant to
my application and relating to my specified offence(s) (as detailed in Section 2).
Yes
By signing this document I understand that:
• the information which I include with my application for a Core Worker
Exemption, and the information released by the New Zealand Police and the
Department of Corrections, will be provided to the
Ministry of Social Development, including to the Core Worker Exemption
Advisor, Core Worker Exemption panel and the decision-maker
• this information is collected under the authority of the Vulnerable Children
Act 2014
• this information will be held by the Ministry of Social Development
• the Ministry of Social Development, the Core Worker Exemption panel and the
decision-maker, will use this information, and any other relevant information
held or collected by the Ministry of Social Development, to assess my
application for an exemption under the Vulnerable Children Act 2014
• the Ministry of Social Development may also use this information for the
purposes of the legislation it administers or to further its statutory
obligations including:
-- the care and protection of children under the Children, Young
Persons, and Their Families Act 1987
-- statistical and research purposes
-- providing advice to Government
-- to avoid prejudice to the maintenance of law
-- to provide assurance to employers or potential employers regarding
fraud or misstatement
• any information disclosed by the New Zealand Police and the
Department of Corrections in accordance with this consent is allowable under
principle 11(d) of the Privacy Act 1993 as I have authorised that disclosure
• if I am working or engaged in a role which is considered to be a core
worker role at a specified organisation, as per the definitions in the
Vulnerable Children Act 2014, and I apply for but am NOT granted an
exemption, my employer will be notified of this outcome
• if I am granted an exemption, which is revoked at a later time, and I am
working or engaged in a role which is considered to be a core worker role
with a specified organisation as per the definitions in the Vulnerable
Children Act 2014, my employer will be notified of this outcome
• the Ministry of Social Development can use or disclose information for
purposes related to your exemption application or status. This may include
disclosing information about your application or exemption status to the
New Zealand Police and other government departments.
Applicant signature
Date
Day
Month
Year
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Core Worker Exemption — IN CONFIDENCE
Additional
7
Information
Please refer to the
Core Worker
Exemption
Application
Guidance for
Individuals for more
information you can
provide to support your
application.
The Core Worker Exemption panel and decision-maker will consider your
application to assess whether you would ‘… pose an undue risk to the safety
of children if employed or engaged as a core worker.’ (Vulnerable Children
Act 2014, S35[2])
To assist the Core Worker Exemption panel and decision-maker in considering
your application, please provide any supporting material you believe may assist.
At a minimum we recommend:
• a letter to the panel outlining:
-- why you wish to be considered for a Core Worker Exemption
-- details of mitigating circumstances or rehabilitation
•
you may also like to include:
-- sentencing notes
-- written personal references from community members
-- written professional references from employers
-- written details from your current employer (if relevant) about any support
or supervision provided in your workplace
-- written evidence of training or education undertaken
-- any other material you want the Core Worker Exemption panel to
consider in support of your application.
Under the Privacy Act 1993 you have the right to ask to see all
information the Ministry of Social Development holds about you and to
ask us to correct that information.
Requests can be referred to the Privacy and Official Information (POI) Team,
PO Box 1556, Wellington or email [email protected]
Submitting your application
Completed application forms and supporting documentation should be:
•
scanned and submitted via email to: [email protected]
OR
• posted/couriered to:
The CWE Advisor
Ministry of Social Development
PO Box 1556
Wellington 6140
Checklist for Application
•
•
•
•
Application form
Copy of identification
Australian Police Check Form (if applicable)
Supporting information
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Core Worker Exemption — IN CONFIDENCE
Proof of
identity
8
Use this section only if you cannot supply a New Zealand driver licence,
passport or firearms licence.
The person confirming your identity (the witness) must:
Please ask someone who
can confirm your identity
to fill in this section. If you
are unable to get
someone to confirm your
identity, you will need to
make an identification
statutory declaration. This
can be carried out at your
local District Court.
• have known you for more than 12 months
• be aged 18 years or over
• have a daytime telephone number and be contactable during normal
business hours
• not be a relative (a relative is a person connected by blood or marriage), and
• not live at the same address.
Witness to complete
Mr
Mrs
Ms
Miss
Other
First and middle names
Surname or family name
Flat/House number
Street name
Suburb
Town/City
Country
Post Code
Home phone
Mobile phone
Email
I declare that I have personally known the person listed below for
and can confim their identity
Mr
Mrs
First and middle names
Ms
Miss
years
Other
Surname or family name
Signature of the Witness
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Core Worker Exemption — IN CONFIDENCE